Expansion of an advance care planning initiative in patients with metastatic cancer: Successes and challenges.

Abstract

197 Background: Advance Care Planning (ACP) activities including dialogs about care preferences, patient goals, and advance directives are an important component of cancer care. A pilot ACP initiative has been expanded to include additional sites of cancer care within the Cedars-Sinai Cancer Health System. Methods: The pilot study including two cancer care sites (started July 2017) was expanded to include two additional sites. The prior results were presented to 86 oncologists at all four cancer care sites to promote increased ACP activities for patients with metastatic cancer and/or refer those patients to palliative medicine (PM). ACP activities were defined as one of the following within the last year: 1) an advance directive (AD) or physician’s order for life sustaining therapy (POLST), 2) an ACP note and/or 3) a PM referral. Patients with metastatic cancer were identified by an EMR M1 designation by the oncologist from July 2021 to March 2022. Oncologists received monthly lists of patients with metastatic disease lacking ACP activities and quarterly scorecards with their ACP completion rate compared to their peers. Results: An average of 1302 unique patients with metastatic cancer were identified each month combined from all four sites. System wide ACP activities were unchanged from a baseline 51% in July 2021 to 53% in March 2022. One site representing, an average of 101 patients/month, increased ACP activities from 16% to 65%. Conclusions: This initiative increased ACP activities since July 2021 for patients with metastatic cancer at one of four sites. The remaining three sites, two of which were part of the pilot from 2017, showed a plateauing of ACP activities despite embedded PM providers, ACP education and monthly feedback to the providers. This may have been from a higher baseline and longer PM presence at those sites. The site showing improvement was given economic incentives to meet Cedars-Sinai priorities for ACP activities and started at a lower baseline, both of which may have contributed to the increase. Further improvement in ACP activities may occur with involvement of clinic reception, nursing and social work along with more broad economic incentive for ACP activities. This increase was primarily from ACP note completion of 53% (PM 18% and AD completion 10%).[Table: see text]